Download Supraventricular arrhytmias in pregnancy

Article*
"Development of the European Network in Orphan Cardiovascular Diseases"
„Rozszerzenie Europejskiej Sieci Współpracy ds Sierocych Chorób Kardiologicznych”
Title: Supraventricular arrhytmias in pregnancy
RCD code: VII-V
Author: Grzegorz Kopeć
Affiliation: Department of Cardiac and Vascular Diseases, Centre for Rare Cardiovascular
Diseases, John Paul II Hospital, Krakow, Poland
Date: 2014.04.10
[* The article should be written in Englis
John Paul II Hospital in Kraków
Jagiellonian University, Institute of Cardiology
80 Prądnicka Str., 31-202 Kraków;
tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88
e-mail: [email protected]
www.crcd.eu
Exacerbation of supraventricular tachycardia (SVT) can develop in 20-40% of women who
had SVT before pregnancy.
Atrioventricular nodal reentry tachycardia (AVNRT) and atrioventricular reentry tachycardia
(AVRT) can usually be terminated by vagal maneuvers. When they are ineffective adenosine
is a drug of choice. Metoporol iv can be used if SVT persists despite adenosine infusion.
Pharmacological prophylaxis should only be used when arrhytmia is not tolerated. Digoxin
and metoprolol are of first choice and sotalol, flekainid and propafenon are of second choice.
If preexcitation is evident from the surface ECG drugs which slow atrioventricular conduction
are contraindicated. Ablation can be considered only in selected patients especially in whom
SVT is associated with hemodynamic instability. In every case of hemodynamically unstable
arrhythmia electrical cardioversion should be used promptly.
Atrial focal tachycardia (AFT) is usually resistant to pharmacotherapy in pregnancy and
frequently associated with structural heart disease. The main aim is to control the ventricular
rate with use of
beta blockers or digoxin to prevent tachyarrhytmic cardiomyopathy. To
prevent AFT sotalol, flecainid and propafenon can be used. Amiodaron can be used only if
other drugs are ineffective. Electrical cardioversion is usually not indicated due to high rate of
recurrence of arrhythmia.
Atrial fibrillation (AFib) and atrial flutter (AFl) in pregnancy usually develop due to
hyperthyroidism or structural heart disease. In case of hemodynamic instability electrical
cardioversion is indicated without delay. In stable patients without structural heart disease
ibutilid and flekainid should be used as a first choice for cardiovarsion. The second choice is
propafenon or vernacalant but there is no evidence on their use for cardioversion of AFib in
pregnancy. The third choice is amiodaron which however can be toxic for the child. If
cardioversion is planned and AFib or AFl lasts for more than 48 hours 3 week anticoagulation
is necessary before the procedure and 4 weeks or longer after cardioversion. Stratification of
cardioembolic risk in AFib or AFl is similar as in nonpregnant patients and is based on the
CHA2DS2VASC criteria. Vitamin K antagonists are recommended in the second trimester
and in the third trimester until 36 week. In the first trimester and last month of pregnancy low
molecular weight heparin in therapeutic doses adjusted to body weight should be used. New
oral anticoagulants should not be used due to the risk for the child. If cardioversion is not
John Paul II Hospital in Kraków
Jagiellonian University, Institute of Cardiology
80 Prądnicka Str., 31-202 Kraków;
tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88
e-mail: [email protected]
www.crcd.eu
considered the rhythm should be controlled with beta blockers (first choice drug) or digoxin
which however does not reduce heart rate during exercise. Werapamil is a second choice
drug. In case of severe symptoms of recurrent AFib or AFl pharmacological prevention with
sotalol or flecainide or propafenon can be used. Flecainide and propafenon need to be
combined with beta blockers. Dronedarone should not be used in pregnancy.
It has been underscored that atenolol should not be used in pregnancy due to the risk of
hypospadias when used in the I trimester and the risk of congenital defects, low birth weight,
bradycardia and hypoglicemia in child when used in II or III trimester.
References
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John Paul II Hospital in Kraków
Jagiellonian University, Institute of Cardiology
80 Prądnicka Str., 31-202 Kraków;
tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88
e-mail: [email protected]
www.crcd.eu
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John Paul II Hospital in Kraków
Jagiellonian University, Institute of Cardiology
80 Prądnicka Str., 31-202 Kraków;
tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88
e-mail: [email protected]
www.crcd.eu
[** Signing the article will mean an agreement for its publication]
John Paul II Hospital in Kraków
Jagiellonian University, Institute of Cardiology
80 Prądnicka Str., 31-202 Kraków;
tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88
e-mail: [email protected]
www.crcd.eu